Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | A64117 | CA |
NPI | 1184634016 |
---|---|
Provider Name | Bernadette Pendergraph |
First Address | Torrance, CA 90502-2047 |
Second Address | Torrance, CA 90502-2047 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A641170 | (05) | CA |
H35470 | (02) | CA |